Transcript: John Frank - What Determines | Oct 22, 2003

(music plays)

A slate reads “The advice given in Mini-Med School is of a general nature only. Viewers should consult their own medical professional for medical advice specific to their circumstances.”

Against a blurry background of blue and pink pills, a video reel displays pictures of medical gear such as a needle, a scan of a human body and heart rate monitors.

The title of the show slides in: “Mini-Med School.”

Then, John Frank stands on a stage in a university auditorium giving a lecture. He’s in his mid-fifties, with a goatee and receding blond hair. He’s wearing glasses, a white shirt and a dark patterned tie.

Behind him, a computer screen is projected on a tall white wall.

John says ONE OF THE BIG
CLUES TO HOW HEALTH IS
DETERMINED IS THE FACT THAT ARE
THESE VERY REGULAR REPEATED
PATTERNS IN EVERY SOCIETY, IN
EVERY EPOCH, ALL OVER THE WORLD
IN HEALTH STATUS AND IT'S RANK-
ORDERED BY YOUR SOCIAL STATUS.

A caption appears on screen. It reads “John Frank. University of Toronto. What Determines Health.”

He continues WE CALL THESE “GRADIENTS” AND
THEY ARE REMARKABLY SIMILAR IN
THEIR SHAPE, SO LEMME SHOW YOU
ONE.
NOW THIS IS A STUDY DONE IN
SCOTLAND, THEY HAVE A
QUESTIONNAIRE IN SCOTLAND CALLED
“THE DEPRIVATION QUESTIONNAIRE.”
AND IT ASKS SOME QUESTIONS LIKE,
DO YOU OWN A CAR?
DO YOU HAVE AN INSIDE PRIVY?
I'M NOT KIDDING.

[Laughter]

John continues AND THEY USE THIS
QUESTIONNAIRE TO BUILD AN INDEX
OF HOW WELL-OFF THE FAMILY IS,
OKAY, IT'S KIND OF A WEALTH AND
INCOME INDEX, ALL RIGHT?
AND THEY GET ANSWERS TO THAT,
THEY WOULDN'T GET ANSWERS TO,
UH, TO HOW MUCH MONEY YOU MAKE.
SO THEY TAKE A LARGE POPULATION
OF SCOTS AND THEY, THEY DO THE
QUESTIONNAIRE ON 'EM AND THEY
FOLLOW THEM FOR 10 YEARS TO SEE
WHO DIES.

He runs a PowerPoint presentation.

He continues AND THEY LOOK BACK AND SEE WHAT
THE RATE OF DEATH IS IN EVERY
DIFFERENT DECILE, THAT'S ALL
THESE -- PARDON ME, SEPTILE,
THESE ARE SEVEN CATEGORIES OF
BEING DEPRIVED, SO THESE ARE THE
MOST DEPRIVED AND THE LEAST
DEPRIVED.

He uses a laser pointer to point at a slide that shows a bar graph.

He continues NOW YOU'LL NOTICE THAT THE WORST
RATIO, THAT IS, THE BIGGEST
DIFFERENCE, THIS IS 100 percent, UH,
DEATH RATE STANDARDS FOR THE
WHOLE STUDY ALL THE PEOPLE, SO
WHAT WE SEE IS THAT IT'S -- IT
RANGES FROM 60 percent OF THAT TO
ALMOST 130 percent OF THAT FOR PEOPLE
WHO ARE YOUNG.
AND IT'S A LITTLE BIT LESS OF A
RATIO, IT'S A LESS STEEP
GRADIENT, IF YOU WILL, FOR OLDER
PEOPLE, WE OFTEN FIND THAT, BUT
IT'S STILL OVERALL PRETTY
IMPRESSIVE BECAUSE IT'S REGULAR.
IT'S ABSOLUTELY REGULAR.
IT'S FRACTAL.
THE FINER YOU DIVIDE IT, THE
SAME PATTERN YOU SEE.
AND IT'S TRUE EVERYWHERE IN THE
WORLD.
SO THAT'S PRETTY PROFOUND AND
THERE'S ANOTHER THING ABOUT IT.
IT'S TRUE FOR MOST CAUSES OF
DEATH.
THERE ARE A FEW EXCEPTIONS,
BREAST CANCER, WE THINK BECAUSE
POOR WOMEN HAVE SOME INHERENTLY
DIFFERENT REPRODUCTIVE PATTERNS
THAT PROTECT THEM.
BUT MOST CAUSES OF DEATH ARE
ALWAYS RANK-ORDERED LIKE THIS,
THE MOST AFFLUENT SUFFER A HALF,
SOMETIMES A THIRD, SOMETIMES
TWO-THIRD OF THE DEATH RATE OF
THE LEAST AFFLUENT AND IF YOU
LOOK ACROSS THAT RANGE OF CAUSES
OF DEATH, YOU'LL HAVE TO AGREE
THAT WHATEVER'S GOING ON HAS TO
BE PRETTY PROFOUND, BECAUSE THE
PATHWAYS IN THE BODY, IN THE
MIND THAT LEAD TO THESE DISEASES
ARE VERY DIFFERENT.
I'LL COME BACK TO THAT.
WHAT ABOUT CANADA, YOU'RE -- I
KNOW WHAT YOU'RE TELLING ME,
YOU'RE SAYING, WELL, THAT WAS
SCOTLAND, YOU KNOW, THEY'RE IN
THE PAST, IT'S A VERY
HIERARCHICAL SOCIETY, SOCIAL
CLASS MATTERS THERE, BUT THIS IS
CANADA, ANYBODY CAN MAKE IT TO
THE TOP.
YEAH, YOU CAN MAKE IT TO THE
TOP, BUT IF YOU DON'T GET TO THE
TOP, YOU'RE GONNA DIE ABOUT
TWICE AS OFTEN IN THE FIRST FIVE
YEARS AFTER YOU RETIRE.

[Laughter]

John says BAD NEWS, IT'S
BAD NEWS, BUT YOU KNOW WHAT?
MAYBE YOU'RE HAVING A BETTER
TIME, I DON'T KNOW, YOU KNOW.

A line graph under the title “Mortality rates: ages 65-70” appears on screen.

He continues HERE'S WHAT WE FOUND OUT, THIS
IS HUNDREDS OF THOUSANDS OF MEN
FOLLOWED IN THE CANADA PENSION
PLAN SYSTEM UNTIL THE CHEQUES
STARTED TO GO TO THE SPOUSE, SO
WE KNOW THEN, WE KNOW, WE KNOW
THEY'RE DEAD, OKAY?--

[Laughter]

John says SO WHAT HAPPENS
IS, IF WE TAKE THEIR EARNINGS,
WHICH ARE ALL, ALL WRITTEN DOWN,
RIGHT, 'CAUSE THAT DETERMINES
THEIR TOTAL CONTRIBUTIONS WHICH
DETERMINES THEIR PENSIONS, ALL
WRITTEN DOWN, SO WE TAKE THEIR
TOTAL EARNINGS FOR THE 20, 21
YEARS BEFORE THEY RETIRED.
SO THIS IS LIKE NOT JUST A
LITTLE TINY GUESSTIMATE OF HOW
GOOD THEIR, THEIR EARNINGS ARE,
THIS IS LIKE PRETTY ACCURATE,
RIGHT AND THEN WE MAP THEIR
DEATH RATE IN THE FIRST FIVE
YEARS AFTER THEY RETIRE, IT'S,
IT'S DOUBLE, IT'S DOUBLE FOR THE
GUYS WHO HAVE THE LOWEST INCOMES
COMPARED TO THESE GUYS.
SO THIS IS NOT NEWS TO THE LIFE
INSURANCE INDUSTRY.
DO YOU THINK THAT THEY SEND THE
SAME NUMBER OF ADVERTISING
NOTICES TO PEOPLE WHO HAVE A
COLLEGE EDUCATION AND PEOPLE WHO
HAVE PRIMARY SCHOOL EDUCATION?
ARE YOU KIDDING?
THEY KNOW, THEY'VE KNOWN FOR
DECADES THAT IF YOU'VE GOT A
COLLEGE EDUCATION, YOUR DEATH
RATE'S DOWN HERE, IF YOU HAVE
PRIMARY EDUCATION, YOUR DEATH
RATE'S UP HERE, WHO DO THEY WANT
FOR CLIENTS?!
THEY POCKET THE
DIFFERENCE, WHEN YOU BUY A
POLICY, THEY GIVE YOU CREDIT FOR
WHAT, AGE, GENDER, SMOKING IF
THEY'RE ANY GOOD, AND DISEASE
STATS, THAT'S WHAT THE LITTLE
EXAM IN THE QUESTIONNAIRE'S FOR.
DO THEY GIVE YOU CREDIT BECAUSE
YOU DID BETTER IN SCHOOL AND
MAKE MORE MONEY?
THEY DO NOT, THEY POCKET THE
DIFFERENCE.
SO THAT'S WHY EVERYBODY WHO
GRADUATES FROM ANYTHING GETS A
SLEW OF LIFE INSURANCE NOTICES,
BECAUSE THEY'RE GOOD CLIENTS.
THEY DON'T DIE AS OFTEN.

A bar graph appears. It reads “Education at University or Polytechnic (percent).”

He continues SO IS THIS THE GENERAL SHAPE OF
THIS RELATIONSHIP?
WELL, THAT'S A LITTLE MORE
COMPLICATED.
IN CANADA, THIS STATUS SHOWS US
THAT IN THE LONG RUN, THE VERY
LONG RUN, 27 YEARS OF FOLLOW-UP
ON AVERAGE, THIS IS THE KIND OF
SHAPE, IT'S PRETTY LINEAR AND
AGAIN, IT'S FRACTAL, LIKE YOU
KEEP SUBDIVIDING IT AND YOU
STILL SEE THE PATTERN, IT NEVER,
IT NEVER WIGGLES UP AND DOWN,
IT'S ALWAYS THE SAME.
THE MORE INCOME, THE LESS YOUR
RISK OF DEATH LATER.
BUT IN THE UNITED STATES, THE
PATTERN LOOKS QUITE DIFFERENT
FOR A DIFFERENT SAMPLE.
THAT IS THAT THIS INCLUDES
EVERYBODY.
THAT FIRST STUDY IN CANADA WAS
ONLY PEOPLE WHO MADE ENOUGH
MONEY TO BE IN THE CPP AND
CONSEQUENTLY THEY WERE REGULAR
EMPLOYED, THEY DIDN'T INCLUDE
UNEMPLOYED OR STREET PEOPLE OR
ANY OF THOSE OTHER FOLKS AND
THEY WERE ALL MEN.
THIS IS A STUDY OF, UH, ALL THE
POPULATION AND THIS IS THEIR
INCOME DISTRIBUTION, THAT'S JUST
THE USUAL SKEWED INCOME
DISTRIBUTION, THE PROPORTION OF
PEOPLE WITH EACH INCOME AND THIS
IS THEIR DEATH RATE AND THAT'S
NOT LINEAR.
WHAT IT SHOWS IS THAT BEING VERY
POOR STEEPLY INCREASES YOUR
DEATH RATE, THIS IS OVER THE
FOLLOWING FIVE TO EIGHT YEARS.
AND WE THINK THIS MAY BE
DIFFERENT FOR A COUPLE OF
REASONS.
FOR ONE THING, IN THE SHORT RUN,
YOU CAN ACTUALLY DIE MORE OFTEN
BECAUSE OF A DISEASE AND THE
DISEASE MAY HAVE CAUSED YOUR
INCOME TO DECLINE, ESPECIALLY IN
THE STATES.
IN THE STATES IT'S STILL
POSSIBLE AND IN FACT, IT'S NOT
UNCOMMON, TO GO INTO POVERTY
BECAUSE OF MEDICAL BILLS.
YOU JUST HAVE TO EXCEED YOUR
ASSURE -- YOUR INSURER'S FINE
PRINT WILLINGNESS TO PAY.
UH, IT'S QUITE EASY, I JUST
LIVED IN BERKELEY, TEACHING AT
THE SCHOOL OF PUBLIC HEALTH
THERE FOR FOUR YEARS, CAME BACK
TO DO THIS JOB, UM, AND IT'S
QUITE EASY TO FIND MIDDLE-CLASS
PEOPLE WHO HAVE BEEN DRIVEN INTO
POVERTY BY THEIR MEDICAL BILLS.
SO THAT WOULD LEAD THEM -- THEIR
DISEASE TO BOTH INCREASE THEIR
DEATH RATE BUT ALSO REDUCE THEIR
INCOME, SO THAT WOULDN'T BE
QUITE A LEGITIMATE TEST OF
WHETHER, UH, THE, THE DEATH
RATE'S CAUSED BY THE INCOME
ITSELF, THAT WOULD BE NOT
APPROPRIATE.
THAT'S CHICKEN-EGG INSTEAD OF
EGG-CHICKEN.
UH, BUT THE OTHER THING IS THAT,
UH, THE AMERICAN SYSTEM HAS A
LOT -- MANY FEWER PROTECTIONS
FROM PEOPLE SLIDING DOWN INTO
THAT.
MANY FEWER PROTECTIONS.
BECAUSE HEALTH CARE MUST BE PAID
FOR, UH, UNLESS YOU'RE ELDERLY
OR DISABLED.
AND SO THE RESULT IS THAT THEY
HAVE MUCH GREATER CHANCE OF
SLIDING DOWN INTO THE VERY HIGH
MORTALITY AND IF YOU SLIDE DOWN
INTO THE REALLY LOW INCOME, IT
JUST, IT MAKES SENSE THAT YOU,
YOU SUFFER MULTIPLE INSULTS THAT
ARE HARDSHIPS AND HARDSHIPS ARE
BAD FOR PEOPLE, AS I NOW WILL
BEGIN TO ARGUE, USING SOME OTHER
MEASURES OF WHAT THE BIOLOGY IS
WHEN WE SUFFER HARDSHIPS.
I'M GONNA USE A FEW SLIDES FIRST
THOUGH, JUST TO TALK ABOUT THE
MOST FAMOUS STUDY OF HOW HIGH
YOU ARE UP THE SOCIAL LADDER AND
YOUR HEALTH, IT'S THE WHITEHALL
STUDY, NAMED AFTER THE BRITISH
CIVIL SERVICE HEADQUARTERS IN
LONDON, SO THESE ARE LARGE
WORKFORCE, THEY HAD 12,000 MEN
IN THE FIRST STUDY AND OVER
10,000 MEN AND WOMEN IN THE
SECOND STUDY NOW IN ABOUT ITS
SECOND DECADE OF FOLLOW-UP AND
THESE ARE ORDINARY BUREAUCRATIC
SOCIAL WORKERS, IT'S NOTHING
UNUSUAL, THEY'RE DIVIDED INTO
PAY GRADES.
NOW THE PAY GRADES ARE JUST WHAT
YOU FIND IN ANY BUREAUCRACY,
RIGHT, BUT THEY'RE VERY CLOSELY
RELATED TO THE EDUCATION, SO THE
PERCENTAGE WHO HAD POST-
SECONDARY EDUCATION, IT'S VERY
HIGH, THESE ARE THE
YES,
MINISTER
TYPES, RIGHT,
THE GUYS WHO HAVE THE OXBRIDGE
ACCENT, YOU KNOW, THE SHINY
SHOES, THEY'RE AT THE TOP OF THE
LADDER.

He points at a new slide and continues
OKAY, AND THEY GET THE MOST
MONEY AND THEN WE HAVE DOCTORS,
LAWYERS, ENGINEERS, DOWN
THROUGH, OKAY, TO THIS IS THE
DUSTMEN, THE SWEEPER, YOU KNOW,
SO THAT'S A NORMAL BUREAUCRACY,
NOTHING SPECIAL ABOUT THAT.
BUT WHEN THEY FOLLOWED THEM UP
TO SEE WHO DIED AND AT WHAT
RATES, FROM ALL CAUSES, THIS IS
WHAT THEY FOUND.
FOUR TIMES AS MANY WERE DYING AT
THE LOWEST END OF THE PAY SCALE
COMPARED TO THOSE IN THE MIDDLE,
THESE ARE DOCTORS, LAWYERS AND
ENGINEERS, NOT EXACTLY, UH, YOU
KNOW, POOR PEOPLE AND THEY WERE
DYING TWICE AS OFTEN AS THE
YES, MINISTER
TYPES AT
THE TOP OF THE LADDER.
SO THEY BEGAN TO THINK, THIS WAS
THE FIRST STUDY AND IN THE
SECOND STUDIES, THEY DESIGNED
IT, THEY SAID, WE GOTTA FIND OUT
WHAT'S GOING ON HERE.
WHAT IS GOING ON IN THE HALLS OF
WHITEHALL THAT KILLS PEOPLE FOUR
TIMES AS OFTEN WHO DON'T MAKE AS
MUCH MONEY?
THEY'RE ALL BEING PAID A LIVING
WAGE, HOW COULD THIS BE?
SO THEY FIRST LOOKED TO SEE IF
THERE WERE CERTAIN CAUSES OF
DEATH, WHERE THE WH -- THE POOR,
THE POORER PAID WERE DYING MORE
OFTEN.
WHITEHALL THAT KILLS PEOPLE FOUR
TIMES AS OFTEN WHO DON'T MAKE AS
MUCH MONEY?
THEY'RE ALL BEING PAID A LIVING
WAGE, HOW COULD THIS BE?
SO THEY FIRST LOOKED TO SEE IF
THERE WERE CERTAIN CAUSES OF
DEATH, WHERE THE WH -- THE POOR,
THE POORER PAID WERE DYING MORE
OFTEN.
THE ANSWER WAS JUST AS WE'VE
SHOWN YOU ALREADY IN THE
SCOTTISH DATA, IT WAS TRUE FOR
ALMOST EVERY CAUSE OF DEATH,
LET'S TAKE THIS GROUP, DOCTORS
AND LAWYERS AND ENGINEERS IS THE
REFERENCE GROUP AND SET THEM AT
1.0.

A slide displays a table under the title “UK Civil Service.”

He continues THEN THE PROPORTION OF DEATHS
FROM THAT CAUSE IN THOSE WHO
WERE HIGHER UP WAS ALWAYS LESS,
SOME SMALL NUMBERS CREATE THE
ZEROS HERE AND THE...
PROPORTION, UH, OF PEOPLE DYING
IN THE NEXT LEVEL DOWN AND THE
LOWEST LEVEL OF PAY WAS HIGHER
IN EVERY CASE.
SOMETIMES SEVEN TIMES HIGHER,
PARTICULARLY WHERE SMOKING IS
INVOLVED.
SO THEY KNEW THERE WERE SOME
THINGS THAT LOOKED EVEN MORE,
MORE HEAVILY WEIGHTED AGAINST
THE POORLY PAID AND MAYBE
SMOKING WAS A FACTOR, THEY SAID,
OKAY, WELL, LET'S TRY AND
CONTROL FOR THAT AND SEE JUST
HOW MUCH THEIR JOB AND THEIR JOB
CONDITIONS CONTRIBUTE TO THIS.
BY THE WAY, SICKNESS ABSENCE WAS
THE SAME, THERE THERE WAS A
SIXFOLD DIFFERENCE IN DOCTOR-
CERTIFIED SICKNESS ABSENCE
BETWEEN THE LOWEST PAID UP HERE
AND THE HIGHEST PAID DOWN HERE.
THAT'S NOT JUST HEALTH, MENTAL
HEALTH DAYS FOR HANGOVERS,
THAT'S MEDICALLY-CERTIFIED
ILLNESS.
THE PROBLEM IS THAT WHEN THEY
LOOKED AT THESE PEOPLE IN
DIFFERENT PAY GRADES, THE MORE
THEY LOOKED AT THEM, THE MORE
THEY WERE COMPLETELY DIFFERENT
ON EVERYTHING.

A table with three columns appears. The first column reads “Grade of Employment: Administrators, professional/executives, clerical, other” The second column reads “Mean Height: 178.5, 176.3, 174, 173.2” And the third column reads “Percent Smokers: 28.8, 37.3, 53.0, 60.9.”

He continues FIRST OF ALL, THE MEN IN THE TOP
PAY GRADE, THE
YES,
MINISTER
TYPES, WERE TWO
INCHES TALLER ON AVERAGE THAN
THE GUYS AT THE BOTTOM OF THE
PAY GRADE!

[laughter]

John continues HOW COULD THAT
BE?
WELL, WE NOW KNOW THAT HAPPENS
FOR TWO REASONS.
WE KNOW THAT SUBTLE MALNUTRITION
AND RECURRENT INFECTION WAS
STILL FAIRLY COMMON IN BRITAIN
OF THE 1930s, '20s AND '40s WHEN
THESE PEOPLE WERE YOUNG.
AND CHRONIC BRONCHITIS IN
PARTICULAR WAS MUCH COMMONER IN
PEOPLE WHO LIVED IN THE SLUMS
AND SMOKING WAS MORE COMMON, ALL
THOSE THINGS AND SO THAT THEY,
THEY DIDN'T -- THEY WERE
STUNTED, TO A DEGREE, BY, BY
THAT COMBINATION OF RECURRENT
INFECTION AND NUTRITION, BUT WE
ALSO KNOW SOMETHING A LITTLE
LESS PLEASANT TO RECOUNT TO YOU.
AND THAT IS THAT YOUR CHANCES OF
BEING PROMOTED IN AN
ORGANISATION ARE, IN FACT,
RELATED TO YOUR HEIGHT.
NOT PERFECTLY.
LEE IACOCCA ISN'T
VERY TALL.
SO YOU CAN GET TO THE TOP IF
YOU'RE SHORT, BUT IT'S MUCH
HARDER.
THIS IS WHAT WE THINK OF AS A
BASIC PRIMATE BEHAVIOUR, IT'S,
IT'S SIMILAR TO THE ALPHA MALE
THING, YOU KNOW, BIG, PEOPLE
LIKE BIG, RIGHT, THEY WANT BIG
TO BE THE BOSS, SO IT'S A WELL-
KNOWN PHENOMENON AND IT'S
UNFAIR.
ANYWAY, FROM THE POINT OF VIEW
OF THE STUDY, THEY SAID, WELL,
WE CAN'T LET THAT INTERFERE WITH
TRYING TO UNDERSTAND HOW MUCH
THEIR WORK ENVIRONMENT
INFLUENCES THEIR DEATH RATES, WE
GOTTA TAKE THAT OUT OF THE
EQUATION AND CONTROL FOR IT.
THEY DID THAT STATISTICALLY.
ALSO LOOK AT THE DIFFERENCE IN
SMOKING RATES AND THIS IS BIGGER
NOW, BECAUSE MOST OF THE
QUITTERS ARE FROM THE UPPER
SOCIO-ECONOMIC GROUPS.
MOST OF THE FAILED QUITTERS ARE
IN THE LOWEST SOCIO-ECONOMIC
GROUPS, BECAUSE THEIR LIFE IS
HARDER, IT'S HARD TO GET ON TOP
OF IT.
AND WE'VE GOT DIFFERENCES IN
NORTH AMERICA THAT ARE EVEN
BIGGER THAN THIS, IN THIS CASE,
THE TOP END AT THAT POINT, THIS
IS IN THE, IN THE, UH, EARLY
'80s, THIRD, A THIRD OF THEM
WERE SMOKING VERSUS NEARLY TWO-
THIRDS OF THE LOWEST PAID.
SO THEY SAID, LET'S TRY AND
CONTROL FOR ALL THIS STUFF,
LET'S SEE HOW MUCH WE CAN
EXPLAIN OF THE DIFFERENCE IN
SOMETHING THAT WE UNDERSTAND, AT
LEAST GIVEN PAUL OH'S TALK YOU
CAN APPRECIATE THAT WE ACTUALLY,
THAT THOSE LITTLE SCORES HE GAVE
YOU FOR RISKS, THAT MEANS WE
ACTUALLY HAVE A BIG MATHEMATICAL
MODEL WHICH TELLS US WHAT YOUR
RISK OF DEATH IS FOR EACH VALUE
OF EACH RISK FACTOR, RIGHT?
THAT'S WHERE HE GETS THOSE.
AND THAT'S CALLED “THE
FRAMINGHAM EQUATION,” IT COMES
FROM FRAMINGHAM, MASSACHUSETTS,
WHERE THEY DID A GREAT STUDY
OVER MANY DECADES OF HEART
DISEASE STARTING IN THE '50s.
SO THEY TOOK THE FRAMINGHAM
MODEL, WHICH IS A BIG
MATHEMATICAL MODEL, THAT
EXPLAINS HEART DISEASE RISK FOR
EACH INDIVIDUAL IN THE STUDY.

He points to a new slide and continues AND THEY SAID, OKAY, HOW MUCH OF
THAT DIFFERENCE BETWEEN THE
HIGHLY PAID
YES, MINISTER
TYPES, SET THEM AT THE REFERENCE
LEVEL OF THE RISK OF 1.0, HOW
MUCH OF THE DIFFERENCE BETWEEN
THEM AND THE NEXT PAID DOCTORS
AND LAWYERS WHO HAVE A 2.1-FOLD
DIFFERENCE IN HEART DISEASE
DEATH RATES, THAT'S CORONARY
HEART DISEASE, VERSUS THE
CLERICAL, THE NEXT LEVEL OF PAY
DOWN, VERSUS THE LOWEST PAID
WORKERS, WHO ARE DYING,
REMEMBER, FOUR TIMES AS OFTEN,
HOW MUCH OF THAT CAN WE EXPLAIN
BY FRAMINGHAM RISK FACTORS THAT
PAUL TALKED TO YOU ABOUT?
LIPIDS, SMOKING, BLOOD PRESSURE,
OTHERS LIKE LEFT VENTRICULAR
ATROPHY, DIABETES, FAMILY
HISTORY, HEIGHT, HEIGHT'S
RELATED TO CORONARY DISEASE,
UNFORTUNATELY IN THE SAME BAD
DIRECTION FOR SHORT PEOPLE.
AND WHAT THEY FOUND, WHAT THEY
FOUND, I'M GONNA HAVE A HARD
TIME WITH QUESTIONS, I CAN SEE
THAT.

[Laughter]

John says MAYBE IF I STOOD
DOWN HERE.
THEY FOUND THAT
OVER HALF OF THE DIFFERENCE
COULDN'T BE EXPLAINED AT ALL.
MEANING THAT, YES, ALL THAT PAUL
TOLD YOU IS TRUE, THOSE RISK
FACTORS MATTER, BUT THEY DON'T
REALLY EXPLAIN THE DIFFERENCES
BETWEEN RICH AND POOR, SO THEY
BEGAN TO LOOK FOR SOMETHING ELSE
AND THEY GOT QUESTIONNAIRES
ABOUT WHAT PEOPLE'S WORK WAS
LIKE TO THEM.
THEY ASKED THEM QUESTIONS LIKE,
DOES YOUR JOB UNDERUSE YOUR
SKILLS?
WELL, THERE WASN'T TOO BIG A
DIFFERENCE, THAT'S KIND OF LIKE
NOT AN INFORMATIVE QUESTION.
50 percent OF THE TOP PAID, ONLY 67 percent OF
THE OTHERS SAID THEIR JOB DIDN'T
USE THEIR SKILL.
BUT LOOK AT THIS ONE, LITTLE
CONTROL OVER THE TASKS OF THE
JOB.
7 percent VERSUS 33 percent.
NOT FAIR TREATMENT IN THE JOB,
11 percent OF THE TOP PAID VERSUS 33 percent
OF THE LOW PAID.
THIS IS THE KILLER.
NO VARIETY, MONOTONOUS JOB.
0 percent OF THE TOP PAID, MAYBE IT'S A
HARD JOB, BUT IT'S NEVER
MONOTONOUS, RIGHT, 37 percent OF THE
LOW PAID.
AND FINALLY JOB WAS OF LITTLE
VALUE, NOBODY WOULD ADMIT TO
BECAUSE THEY'RE BRITISH.

[Laughter]

He continues SO THEY TOOK
THESE RESULTS AND THEY SAID,
WELL, LET'S FOLLOW PEOPLE WHO
HAVE DIFFERENT LEVELS OF CONTROL
IN THEIR JOB OR THE
PSYCHOLOGICAL DEMANDS OF THEIR
JOB, WHICH THEY MEASURED WITH
QUESTIONNAIRES AND THEY FOLLOWED
THEM UP.
NOW WHAT WE EXPECT TO SEE, WHEN
WE MEASURE SOMETHING LIKE
PSYCHOLOGICAL DEMANDS OR THE, OR
THE DECISION LATITUDE OR CONTROL
OF YOUR JOB, WITH
QUESTIONNAIRES, IS WE EXPECT TO
SEE THAT THE BAD COMBO, THINK OF
YOUR BOSS NOW, IF YOU WORK FOR
PAY, THINK OF YOUR BOSS.

A new graph appears under the title “Job characteristics and heart disease prevalence. Swedish males, 1974.”

He continues IF HE -- WHEN YOU HAVE HIGH
DEMANDS, THAT'S YOUR BOSS COMES
IN AND SAYS IT'S DUE TOMORROW
AND, YOU KNOW, THAT'S IT, THAT'S
A HIGH PSYCH DEMAND SITUATION,
THAT'S BAD, RIGHT, SO YOUR RISK
OF HEART DISEASE WILL BE HIGH,
LIKE IN THIS SWEDISH STUDY OF
CHEST PAIN AND THE BAD SITUATION
DOWN HERE IS WHERE YOU CAN'T
NEGOTIATE, YOU CAN'T NEGOTIATE
WITH HIM, THAT'S THE KIND OF
SITUATION IT IS, RIGHT, SO YOU
HAVE NO CONTROL AND THAT'S,
THAT'S LOW CONTROL, SO THAT'S
THE WORST QUADRANT TO BE IN,
RIGHT?
HIGH DEMAND, LOW CONTROL, SO
WHAT OTHER STUDIES SHOW THAT
COMBINATION IN A JOB GIVES YOU
IN THE WAY OF RISK OF HEART
DISEASE?
WELL, WE HAVE 36 STUDIES, IN
MORE THAN HALF OF THEM, JOB
CONTROL WAS RELATED TO
CARDIOVASCULAR DISEASE, JOB
DEMAND'S A LITTLE BIT MORE
PROBLEMATIC, BUT THIS IS THE
BEST STUDY AND I'M, I'M JUST
SHOWING YOU THIS SO THAT YOU
KNOW THAT THIS RISK FACTOR IS AS
POWERFUL AS SMOKING.
OKAY?
IT'S JUST THAT YOUR DOCTOR
DOESN'T KNOW ABOUT IT AND IF HE
DID, I'M NOT SURE HE'D WANNA ASK
YOU, BECAUSE WHAT'S HE GONNA DO
ABOUT IT?
BUT MAYBE HE SHOULD, SHE SHOULD.
MAYBE THAT SHOULD BE PART OF THE
HOLISTIC APPRAISAL OF YOU AS
SOMEBODY WHO HAS RISK FACTORS.
THIS STUDY IN THIS ENORMOUS
NUMBER OF SWEDISH MEN FOLLOWS
FOR 14 YEARS FOR DEATH DUE TO
CORONARY DISEASE SHOWED THAT
ALMOST, THEY WERE ALMOST TWO
TIMES MORE LIKELY TO DIE IF THEY
HAD LOW CONTROL OVER THE TASKS
OF THEIR JOB AND IF THEY HAD LOW
SOCIAL SUPPORT AT THEIR JOB,
MEANING THEIR SUPERVISOR AND CO-
WORKERS WEREN'T SUPPORTIVE OF
THEM, IT WAS ALMOST THREE TIMES
MORE LIKELY AND THEY CONTROLLED
FOR EVERYTHING.
MAYBE TOO MANY THINGS.
SO IT MATTERS, IT'S JUST NOT OUT
THERE ON THE STREET.
AND OF COURSE, WORKPLACES THAT
ARE SMART ARE INTO MORE FLAT
DESIGNS AND DECISION MAKING
THAT'S MORE DEMOCRATIC TO TAKE
SOME OF THIS OUT OF THE JOB.
NOW I PROMISED YOU A LITTLE BIT
ABOUT THE BIOLOGY, THIS IS
ANOTHER THEME OF THIS LINE OF
THINKING.
BECAUSE ALL OF THIS IS FINE, BUT
IF WE DON'T KNOW ANY BIOLOGY TO
EXPLAIN IT, WE'RE NOT GONNA
CONVINCE ANYBODY, CERTAINLY
NOBODY WITH AN M.D.
SO WE LOOK FOR CONNECTIONS THAT
WILL EXPLAIN -- THIS WORD
PROTEAN MEANS NON-DISEASE-
SPECIFIC.
THE KIND OF PATTERN WE'VE SEEN
HAS CROSSED MANY UNRELATED
DISEASES, SO WE HAVE TO BE ABLE
TO EXPLAIN THAT AND WE HAVE TO
SAY HOW DOES THE SOCIAL
ENVIRONMENT GET UNDER THE SKIN
TO CAUSE DISEASE FOR BODY -- IN
MANY BODY ORGAN SYSTEMS, HOW CAN
THAT BE?
AND WHAT WE THINK NOW IS THAT
IT'S DUE TO PATHWAYS THAT START
IN THE BRAIN WITH OUR FEELINGS,
WHETHER THEY'RE CONSCIOUS OR
UNCONSCIOUS AND MOVE DOWN
THROUGH PSYCHONEUROIMMUNOLOGY,
MEANING THE PATHWAYS THAT LINK
THE BRAIN, THE NERVOUS SYSTEM
AND THE IMMUNE SYSTEM AND
ANOTHER WORD MISSING HERE,
PSYCHONEUROENDOCRINE.
THE HORMONES THAT ARE PRODUCED
IN OUR BODY AS A RESULT OF OUR
FEELINGS.
SO JUST TO REMIND YOU, THIS IS A
SLIDE FROM THE BRITISH BIRTH
COHORT THEY FOLLOWED -- YOU'VE
SEEN THE FILM
SEVEN UP,
ALL THESE PEOPLE FOLLOWED ALL
THROUGH THEIR LIVES, OKAY, WELL,
THIS IS THE RESULT OF THEIR
HEALTH AT AGE 33, NOW WHEN
THERE'S, WHEN YOU'RE 33, THERE'S
NOT A LOT OF SERIOUS DISEASE
YET, SO YOU HAVE TO USE MEASURES
LIKE MENTAL HEALTH AND THE
PROPORTION OF PEOPLE AT AGE 33
IN THAT ORDINARY GROUP OF BRITS
BORN IN 1958, THE PROPORTION OF
PEOPLE WHO HAD MENTAL HEALTH
PROBLEMS BY GENDER, MALES AND
FEMALES, RANGED FROM LESS THAN
5 percent IF THEIR FATHER WAS RICH, TO
OVER -- NEARLY 15 percent, WELL, SORRY,
8 percent IN MEN AND OVER 15 percent IN WOMEN
IF THEIR FATHER WAS POOR AT
BIRTH AND THIS HAS NOTHING TO DO
WITH THEIR CHANGING THEIR INCOME
THROUGH LIFE, 'CAUSE THIS IS
THEIR PARENTS' SOCIAL CLASS AT
BIRTH.
WHAT ABOUT SELF-RATED HEALTH?
YOU MAY SAY, WELL, WHO CARES
ABOUT THAT, THAT'S NOT A
DOCTOR'S DIAGNOSIS, THAT'S WHAT
THEY THINK.
WELL, TURNS OUT YOUR RATING OF
YOUR HEALTH IS HIGHLY PREDICTIVE
OF YOUR MORTALITY IN THE NEXT 10
YEARS.
SO WHEN YOU ASK PEOPLE, THEY'RE
ONLY 33, THEY SHOULD BE, YOU
KNOW, PEAK OF LIFE, EH, REALLY,
BUT NOT, THEY'RE NOT, LOOK AT
THIS.

He uses the pointer to describe a slide that shows a bar graph.

He continues A BUNCH OF THEM, THE PERCENT WHO
RATE THEMSELVES AS POOR GO FROM
8 percent IN THE PEOPLE WHOSE FATHERS
WERE RICH, LOOK AT THIS, OVER
15 percent AMONG MEN AND ALMOST EXACTLY
THE SAME IN WOMEN FOR FATHERS
WHO WERE POOR.
SO THE ROOTS OF ILL HEALTH ARE
VERY EARLY, VERY EARLY IN LIFE
AND I NEED TO SHOW YOU THE SAME
GRADIENT FOR OBESITY.
SO THERE ARE, UH, SCHEMATIC
REPRESENTATIONS THEN OF THE
PATHWAYS THAT TALK BETWEEN THE
BRAIN, OUR FEELINGS AND OUR
THOUGHTS, OUR PERCEPTIONS AND
OUR ENDOCRINE SYSTEM, UH, THE
ADRENAL CORTEX, UH, AND THE
IMMUNE SYSTEM, WHERE THERE ARE
MANY CHEMICALS SECRETED THAT,
THAT TALK BOTH WAYS.

The slide changes and displays a diagram with arrows.

He continues THE BRAIN CAN HEAR WHAT'S GOING
ON IN THE BODY WHEN IT'S
INSULTED AND IT RESPONDS AND
VICE VERSA.
IF YOU HAVE A BAD DAY, YOU ARE A
STRESSED-OUT, YOUR ARTERIES ARE
NOT HAVING THE SAME CHEMICALS
COURSE THROUGH THEM AND THE
LINING OF YOUR ARTERIES, WHERE
AERTERIO-SCLEROTIC PLAQUE IS
BUILDING UP AND WHERE THROMBOSIS
OR CLOTS WILL CAUSE HEART
ATTACKS OR STROKES, ARE NOT
BEHAVING IN THE SAME WAY.
AND YOU CAN GET AWAY WITH THAT
WHEN YOU'RE 25, 35, 45, NOT IF
YOU'RE GENETICALLY LOADED, 55
MAYBE EVEN IF YOU'VE GOT NORMAL
GENETIC RISK.
65, ANYBODY WITH THAT HISTORY,
WE START TO GET THE, THE EVENTS
YOU SEE HERE.
BUT WESTERN MEDICINE WASN'T
INTERESTED AND IN THE FRAMINGHAM
STUDY STARTED IN 1948 OR 9, THEY
DIDN'T MEASURE ANY PSYCHO-SOCIAL
FACTORS, BECAUSE THEY WERE
OBSESSED WITH LABORATORY
MEASURES THAT THEY COULD, COULD,
COULD USE DRUGS ON.
I'M PUTTING IT NASTILY, BUT
THAT'S WHERE THEY WERE AT.
SO IT'S TRUE, WE HAVE GOOD WAYS
TO CONTROL BLOOD PRESSURE,
CHOLESTEROL AND WE CAN WORK ON
SMOKING, BUT MEANWHILE, WE
FAILED TO LOOK UNTIL VERY
RECENTLY AT ALL THESE OTHER
THINGS IN OUR LIVES WHICH
PROBABLY MAKE A HECK OF A
DIFFERENCE.
THERE'S GENETICS, AS WELL, I-
I'VE REPEATEDLY MENTIONED IT IN
PASSING, I HAVE ANOTHER WHOLE
TALK ON THAT, MICHAEL, INVITE ME
BACK ANOTHER TIME FOR THAT ONE,
BUT BASICALLY IT'S NOT GENETICS
ALONE, THAT'S RARE.
THAT EXPLAINS RARE CHILDREN'S
DISEASES WHERE ONE GENE IS THE
CAUSE.
THAT'S LESS THAN 2 percent OF ALL THE
ILL HEALTH IN OUR SOCIETY.
WHERE GENETICS MATTERS IS WHERE
IT COMBINES WITH BAD
ENVIRONMENTS AND SUSCEPTIBLE
PEOPLE AND THESE STUDIES ARE IN
RHESUS MACAQUES, THEY'RE
COLONIAL, UH, PRIMATES, THEY'RE
A MEDIUM SIZE MONKEY AND I'VE
BEEN TO THE COLONY WHERE THEY'RE
FREE LIVING AND ALLOWED TO FORM
THEIR OWN SOCIETAL BONDS OUT --
SO OUTDOORS IN A VERY LIGHT,
NICE SETTING OUTSIDE BETHESDA,
AND THEY'RE NOT TREATED CRUELLY
AT ALL, THEY'RE OBSERVED FOR
THEIR SOCIAL RELATIONSHIPS AND
THEN, UM, THEY ARE LOOKED AT IN
TERMS OF THEIR CHILD-REARING,
'CAUSE THEY VARY IN THEIR
SKILLS, JUST LIKE HUMANS AND
THEY HAVE DONE BLOOD TYPING TO
SHOW CERTAIN GENES, WHEN
COMBINED WITH BAD PARENTING LEAD
TO MENTAL BREAKDOWN IN THE
OFFSPRING.
DEPRESSION AND/OR ANXIETY
DISORDER THAT PARALYSES.
NOW WE ALL KNOW THIS.
WE CALL IT THE HIGH-STRUNG BABY,
THE HIGH NEEDS BABY, THE
DIFFICULT BABY, WE KNOW BABIES
ARE BORN INTO DIFFERENT KINDS OF
PERSONALITIES AND EITHER PEOPLE
CAN COPE OR THEY CAN'T AND SOME
PEOPLE IT'S NOT THEIR FAULT.
THEY THEMSELVES WEREN'T WELL
PARENTED AND THEY HAVE THEIR OWN
PROBLEMS AND THEY'RE NOT
BRILLIANT AT DEALING WITH THIS
KIND OF NEED.
AND SO WHAT HAPPENS IS, THE
COMBINATION LEADS TO LIFELONG
PROBLEMS AND IT'S MUCH MORE
COMMON IN SOME SOCIAL GROUPS
THAN OTHERS, PRESUMABLY BECAUSE
OF THE HARDSHIPS.
WHAT ABOUT EARLY LIFE
CONSEQUENCES 50 AND 60 YEARS
LATER?
WELL, IT TURNS OUT AND THIS IS
NOT MEANT TO BE READ, IT'S MEANT
TO REMIND ME TO TELL YOU THE
STORY, THAT, THAT THERE IS AN
EXTRAORDINARY AND PREVIOUSLY
UNSUSPECTED RELATIONSHIP BETWEEN
PERINATAL FEATURES OF THE BABY,
LIKE HOW HEAVY THEY ARE AT
BIRTH, BIRTH WEIGHT AND THEN HOW
MUCH WEIGHT THEY GAIN IN THE
FIRST YEAR AND THEIR CHANCES OF
HEART DISEASE 50 YEARS LATER.
AND THIS WAS SHOWN BECAUSE DAVID
BARKER, A BRITISH
EPIDEMIOLOGIST, MANAGED TO FIND
OLD NURSING HOME VISIT RECORDS
FOR HEREFORDSHIRE, I SAID THAT
RIGHT?
HEREFORDSHIRE, HEREFORDSHIRE, I
KNOW, I KNOW, I KNOW IT'S ONE OF
THOSE WORDS, RIGHT?

A slide shows a study under the title “Weight in infancy and death from ischaemic heart disease.”

He continues UH, THEY WERE
BORN 1911 TO 1930, HE FOUND 5654
RECORDS OF THEIR BIRTH WEIGHT
AND WEIGHT AT FIRST YEAR OF, OF
WHAT, FIRST YEAR, END OF FIRST
YEAR, THEY WERE ALL BREASTFED SO
THEY GOT RID OF THE OTHERS,
'CAUSE THEY -- THAT TIME, MOST
PEOPLE WERE, THEY DIDN'T WANNA
MESS WITH THAT EXTRA VARIABLE
AND THEY SHOWED THERE WAS A
THREEFOLD DIFFERENCE IN THEIR
DEATH RATE 50 YEARS LATER IF
THEY WERE LOW BIRTH WEIGHT AND
DIDN'T GAIN MUCH IN THE FIRST --
END OF FIRST YEAR OF LIFE.
SO FOR A LONG TIME WE WEREN'T
SURE WHETHER THIS WAS JUST
BASICALLY HIM STUDYING POVERTY,
PERSISTENT POVERTY, BUT NOW WE
KNOW FROM REPLICATIONS IN OTHER
COUNTRIES THAT HE'S ON TO
SOMETHING.
WE DON'T UNDERSTAND IT, BUT
WE'RE VERY WORRIED ABOUT IT.
WE'RE WORRIED ABOUT IT BECAUSE,
AS YOU PROBABLY KNOW, WE'RE
SAVING, IN CANADA AND IN ALL
WESTERN NATIONS, VERY LARGE
NUMBERS OF BABIES WHOSE BIRTH
WEIGHTS ARE DISTINCTLY ABNORMAL.
AND THAT IS A WONDERFUL THING
FOR THE FAMILIES CONCERNED.
AND WHENEVER POSSIBLE, THE -- WE
DO EVERYTHING TO MAKE SURE THE
BABIES DEVELOPED NORMALLY, BUT
NONE OF THOSE BABIES HAVE BEEN
FOLLOWED FOR 50 YEARS.
SO WE DON'T KNOW WHETHER WE'RE
GONNA REAP A WHIRLWIND DOWN THE
STREET, WE JUST DON'T KNOW.
I WOULD THINK THAT THOSE PEOPLE
NEED SPECIAL ADVICE ABOUT
KEEPING HEALTHY IN EVERY WAY
THEY CAN.
WE HAVE SOME GOOD NEWS, IT'S
BEEN A LOT OF BAD NEWS FOR YOUR
FOLKS TONIGHT, UH, LESS FOR THE
TALL FOLKS IN THE AUDIENCE,
BUT...

[Laughter]

John continues I-I'VE GOT SOME
GOOD NEWS FOR EVERYBODY AND THAT
IS, YOU KNOW, SOME PEOPLE HAVE
TAKEN THE STORY I JUST TOLD AS
KIND OF A FATALISM, A SIGN THAT
THEY CAN'T CHANGE WHAT HAPPENS
TO THEM, THEY'RE PROGRAMMED,
THEIR LIFE DISEASE PATTERN IS
SET RIGHT OUT OF THE WOMB IN THE
FIRST YEAR AND -- NOT TRUE.
ONE OF THE BEST STUDIES SHOWING
HOW ELASTIC, HOW MALLEABLE HUMAN
BEINGS ARE IF THEY GET THE RIGHT
KIND OF STIMULATION IS A
CONTROLLED, RANDOMISED CONTROL
STUDY, SMALL STUDY FROM
YPSILANTI IN MICHIGAN.
IT'S CALLED “THE PERRY PRESCHOOL
PROJECT.”
NOW THIS WAS A, A CHARISMATIC,
UH, INVESTIGATORS OR
PSYCHOLOGISTS' ATTEMPT TO TAKE
GHETTO KIDS AT THE EDGE OF
YPSILANTI AND GIVE THEM
STIMULATION WITH ADULTS TEACHING
THEM BOTH FINE MOTOR SKILLS,
SPEECH SKILLS, COMMUNICATION,
GAME PLAYING, AFTER AND BEFORE
SCHOOL, A FEW DAYS A WEEK FOR A
FEW YEARS BEFORE THEY STARTED
GRADE ONE.
AND OF COURSE, THEY WERE HOPING
TO IMPROVE THEIR SCHOOL SUCCESS,
RIGHT?
SO THEY FOLLOWED THEM, INITIALLY
THEY DID A LITTLE BETTER IN
SCHOOL THAN THE KIDS WHO GOT
ORDINARY, ORDINARY PRESCHOOL
CARE.
THEN THEY KIND OF WASHED OUT,
WHEN THEY GOT THROUGH THE END OF
PRIMARY SCHOOL, YOU KNOW, STUFF
WASHES OUT BECAUSE IT'S BEEN A
LONG TIME SINCE YOU DID THE
INTERVENTION AND SOCIETY IS
SOCIETY AND THEY'RE POOR KIDS,
RIGHT?
BUT THIS GUY, HE WAS UNUSUAL, HE
SAID, I'M GONNA GET MONEY TO GO
BACK AND SEE HOW THEY'RE DOING
NOW THEY'RE 27 YEARS OLD.

He turns to point at a new slide that displays a bar graph.

He continues HE WENT BACK AND FOUND THAT
THOSE WHO'D HAD THE PRESCHOOL
STIMULATION PROGRAM, THESE ARE
ALL POOR KIDS, THEY'RE THE SAME
IN BOTH PROGRAMS, HAD THIS
DIFFERENCE.
THE DIFFERENCE BETWEEN THE --
THE PROPORTION WHO HAD 2,000 OR
MORE IN MONTHLY EARNINGS WAS
THIS HUGE DIFFERENCE WITH THIS
PROPORTION IN THE TREATMENT
GROUP AND THIS TINY LITTLE GROUP
HERE HAVING ADEQUATE INCOME IN
THE CONTROL GROUP.
HOMEOWNER AT 27, 29 percent VERSUS 7 percent.
HIGH SCHOOL GRAD, 36 percent VERSUS
13 percent.
SOCIAL SERVICES IN THE LAST 10
YEARS, CONTROL GROUP, OF COURSE,
RECEIVING MORE, BUT EVERYBODY IN
THIS COMMUNITY GETS A LOT OF
SOCIAL SERVICES AND LOOK AT THIS
ONE, FIVE OR MORE ARRESTS BY AGE
27, THEY, THEY PRACTICALLY PUT
THAT IN A QUARTER, TO A QUARTER
OF ITS VALUE IN THE CONTROL
GROUP.
NOW THOSE AREN'T DIRECT HEALTH
MEASURES, BUT THEY PREDICT
HEALTH, BECAUSE THEY'RE MEASURES
OF SUCCESS AS AD -- AN ADULT IN
SOCIETY.
AND WE'VE SHOWN YOU ALREADY THAT
THE MORE SUCCESSFUL YOU ARE AS
AN ADULT, THE LONGER YOU'LL LIVE
AND THE LESS YOU'RE GONNA COST
THE HEALTH CARE SYSTEM.
SO THE TRUTH IS THAT WE CAN DO A
LOT IF SOCIETY CARED ENOUGH TO
DO EARLY CHILDHOOD INTERVENTION
FOR DISADVANTAGED KIDS.
THIS IS THE MOST WORRISOME
SLIDE, IT'S FRASER MUSTARD
SLIDE, IT SAYS, LOOK, WHILE WE
DECIDE WHETHER WE WANT TO HAVE
QUALITY DAY-CARE FOR EVERYBODY
WHO NEEDS IT, WHICH WILL BUILD
THEIR SOCIAL AND COGNITIVE
SKILLS, WE'RE SPENDING THE WHOLE
MORTGAGE ON PEOPLE IN THE LAST
TWO TO FOUR WEEKS OF LIFE.
WHEN YOU'RE ADMITTED, AND YOU
WILL BE, UNLESS YOU'RE LUCKY
ENOUGH TO DIE AT HOME, TO AN
INTENSIVE CARE UNIT, PERHAPS AT
AN ADVANCED AGE, BETTER MAKE
SURE YOUR ADVANCE DIRECTIVES ARE
IN GOOD ORDER.
MEANING A CLEAR-CUT LETTER
LISTING WHAT YOU WANT DONE,
UNDER WHAT CIRCUMSTANCES YOU'RE
WILLING TO HAVE, UH, EXCESSIVE
MEASURES OR DRASTIC MEASURES
TAKEN, UM, THERE ARE LOTS OF
RESOURCES AVAILABLE TO MAKE SURE
THAT YOU PROVIDE -- PRODUCE A
LETTER THAT'S IN YOUR DOCTOR'S
FILE, I WOULDN'T LEAVE IT TO
YOUR DOCTOR'S FILE, IF YOU GO IN
ON THE WEEKEND AND THE DOCTOR'S
CLOSED, YOU SHOULD HAVE IT IN
YOUR WALLET.
I'M NOT KIDDING.
BECAUSE THE TRUTH IS, IT'S EASY
FOR US TO SPEND 100,000 BUCKS IN
YOUR LAST MONTH OF LIFE.
THAT WOULD BUY A LOT OF
PRESCHOOL, BUT IT'S NOT GONNA
BUY YOU MUCH.
SO IT'S VERY IMPORTANT THAT WE
DON'T DO WHAT TECHNOLOGY IS
INCREASINGLY ALLOWING US TO DO,
WHICH IS TO SPEND ALL OF THE
KITTY OF PUBLIC SECTOR RESOURCES
ON LATE LIFE MEDICAL CARE, WHEN
WHAT WE NEED IS TO MAKE THESE
INVESTMENTS EARLY TO KEEP PEOPLE
HEALTHY, NOT TO SAY THAT ANYBODY
SHOULDN'T GET GOOD CARE WHEN
THEY'RE OLD, OF COURSE WE WANT
GOOD CARE, BUT WE WANT PEOPLE TO
HAVE A DELIBERATE CHOICE ABOUT
WHETHER THEY'RE GONNA BE
AGGRESSIVELY TREATED WHEN THEY,
WHEN THE JUDGEMENTS ABOUT THEIR
CHANCE OF SURVIVAL ARE CLEAR-
CUT.
IN A NUTSHELL, AND THIS IS
SOMETHING THAT THE UNITED
NATIONS HAS SAID, CHILDREN HAVE
THE FIRST CALL ON A NATION'S
RESOURCES IN BAD TIMES AS WELL
AS GOOD.
THANK YOU.

[Applause]

A slate pops up. It reads “For more information about Mini-Med School at the University of Toronto visit us on the web at: www.tvo.org.”

The end credits roll.

Mini-Med School Producer, Wodek Szemberg.

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A Production of TVO Ontario.

Copyright The Ontario Educational Communications Authority 2003.

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